May 23, 2005

Romney and Health Care

I have not had access to a computer since late last week, but I have been thinking about recent comments by Tim Murphy, a senior advisor to Governor Mitt Romney. Murphy has proposed that hospitals and other health care providers in Massachusetts be more aggressive in collecting deductibles and copayments from patients who do not pay. Murphy's comments have been criticized in a number of quarters, including Health Care For All, Blue Mass. Group, and Left in Lowell.

I have a somewhat different take from Murphy's critics. First, I think that Tim Murphy is one of the most thoughtful policymakers in the Romney administration. I don't know that he is advocating draconian collection measures, such as liens on cars and homes. Certainly, any sensible policymaker would see these steps as last resorts. I would think that Murphy would be looking toward hospitals and other health care providers to more actively take other types of collection measures, such as arranging payment plans with patients who have fallen behind on their payments of deductibles and copays. Currently, it can be difficult and costly for health care providers to engage with such patients even to get them "to the table." I know of health care providers who sometimes forego collection measures on even large bills because of the time and expense. One provider I know also said that in his experience it is usually people who can afford to pay that successfully avoid paying. Perhaps Murphy is thinking of ways in which the state government might enact changes that will facilitate stronger collections without putting people on the street.

Pursuing the strongest possible collection rates from patients without resorting unnecessarily to draconian measures is both a matter of equity and financial stability. To the extent that hospitals and other health care providers do not collect their debts, these costs are passed on to the rest of us. To the extent that this is not a matter of an inability to pay - in many cases, it is not - it is an unfair burden for the rest of us to carry the "deadbeats." Also, uncollected debts are contributing to the accelerating cost of health care. Bringing health care costs under control requires financially sensible measures, such as collecting outstanding bills.

I can point to another sector where financial stress forced organizations to improve collection rates - with some initial concerns similar to those expressed by my fellow bloggers and others. Before the passage of Proposition 2 1/2, cities and towns were not necessarily under pressure to collect the bulk of the property taxes owed to them. After the enactment of Proposition 2 1/2, cities and towns came under intense pressure to collect every dime owed to them. Tax collectors and treasurers increasingly used the legal means available to them to induce taxpayers to make them pay their back taxes. There were fears that many people, including the elderly, would be "thrown into the street." In response to such fears, collectors and treasurers generally worked out payment plans with taxpayers who could not afford large cash payments. The approach that many tax collectors and treasurers have taken on tax collections have enabled cities and towns to better weather the fiscal stresses of the past few years.

In conclusion, I would say that John McDonough of Health Care For All did raise good points in his letter to the Boston Globe. Collection measures do need to take ability to pay into account. Employers do need to be part of the solution on health care costs. In counterpoint to John, though, I would say that while it is true that health care is not a luxury, neither is housing. No one disputes that renters and homeowners need to pay rent, mortgages, and taxes - we should be able to arrive at a point in which the same is said about health care costs. Part of the process we now going through on health care is debating how we might make the system both fairer and more financially sensible.

Comments

I get what you're saying, but here's my experience with "ability to pay":
I went to the hospital pay clerk to find out if I qualify for any type of assistance. I didn't. We make too much money. Which is to say, I make just enough to cover rent in MA, basic expenses, food (which I've noticed going up in the last few years), and that's about it. But because we're not destitute, we don't get any sort of help or consideration.

The second issue when you're uninsured is what you get charged vs. what they would charge an insurance company (http://www.cbsnews.com/stories/2004/06/25/health/main626132.shtml). So the uninsured get stuck with a bill that is far higher, and harder to pay, which in turn eats into a hospital's profits, which in turn makes them charge more...

So it's all well and good to be (unaggressively?) pursued for one's outstanding hospital bills, but the standards they use to determine your ability to pay need to change drastically, like taking into account your rent and other expenses. We have school debt, credit debt (mostly from one or the other of us being laid off over the years). Then you add the over-charged expense of being uninsured - I think there's a lot of people out there who *look* like they have ability to pay, but who can't. Sometimes it's a choice between paying off high-interest debt instead of the less fiscally-damaging medical debt. The only way you are going to change that is enforcing aggressive debt collection that makes it as painful for people to fail to pay down medical debt as it is for other types of debt. Which may or may not be what Romney's people advocate - but which would be detrimental to those of us caught in the middle.

Obviously, this is an anecdotal account of my own experience, but if I'm stuck here, I have to imagine there are quite a few like me. Our income is decent but average, and our debt is actually lower than most people my age (which astounds me). We live in an apartment that is in a decent location, but is fairly small and rent is about average, in Lowell, which is a lot lower than living near Boston where my husband works. We've done all we can to lower our personal costs, and still can't afford health insurance or to pay off our medical debt. While using "non-aggressive" debt collection for medical expenses might bring in some cash for these hospitals, I wonder how much they would really get for their trouble.

"I would say that while it is true that health care is not a luxury, neither is housing. No one disputes that renters and homeowners need to pay rent, mortgages, and taxes - we should be able to arrive at a point in which the same is said about health care costs."

The problem with that is that housing costs, while significant (especially around these parts), are generally predictable. You basically know how much you can pay a month for housing, and you choose your house or apartment accordingly. Health care costs, in contrast, are unpredictable and at times astoundingly large. Only the very rich would have any reasonable chance of being able to afford the full cost of a major surgical procedure brought on by an unexpected event (heart attack, bad fall, intestinal blockage, you name it). That is why unexpected health care costs and bankruptcy are so closely linked (see this article: http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.63/DC1). So to me, to equate housing and health care costs is a bit apples-and-oranges-ish.

Also, there are several points in your post where you have to give Murphy a HUGE benefit of the doubt - "I don't know that he is...," "Perhaps Murphy is thinking of...," etc. Murphy's comments caused the outcry that they did precisely because they seem so focused on a single strategy, namely, getting hospitals to collect debt more aggressively. From what he actually said, there's no reason to give him the kindly reading that you ascribe. He may well have other ideas in mind if he's as thoughtful a guy as you say he is (I don't really know anything about him), so maybe this is just an example of Romney's ham-handed PR operation doing a lousy job of getting its message out (see this post: http://bluemassgroup.typepad.com/blue_mass_group/2005/05/romneys_operati.html). But people can't really judge policies on what they think might be in the policymakers' heads - you have to go by what they say. And what he said wasn't very pretty.

Finally, if you allow HTML in your comments, you won't have people like me leaving annoyingly long URLs in their comments!

Note: the links in my comment don't quite work because a final parenthesis and period got stuck onto each of them. If you click the link and then delete the final parenthesis and period at the end of the URL in the address bar, you should get to the right place.

One can't blame bloggers with a no-html-link policy...when setting up my blog, I had to decide whether or not to allow them. Having had another news site previous, and having someone come in and spam the comments with porn links, I can kinda understand it...

The software I used for my site does have some neat options, however, so I can allow a set number of links (spammers generally put in a gazillion). And if there's ever an issue, I can take further steps with some plugins. :) (Anyone that ever needs help with installing their own site, let me know, I'd be happy to help).

On the technical issue of allowing HTML in the comments, I'll look into it.

On the substantive issues, Lynne and David raise some good points. David's point about the unpredictability of medical costs is one of the fundamental reasons why affordable health insurance needs to be provided for those who are currently uninsured. (Lynne's point about the differences between how the uninsured are billed versus insurance companies also strongly supports this.) Governor Romney and Senate President Travaglini have proposed such plans - it remains to be seen what the affordability and quality of health care will be under those plans.

I am giving Tim Murphy the benefit of the doubt. This is based on his past performance on other issues, particularly school building assistance.

My main point in this post and others is that accelerating health cost increases are unsustainable. I think that part of the solution to this is making sure that affordable health insurance is available to all so that people can and will pay what they truly can afford for health care. Collecting outstanding debts is another measure that will ultimately bring down costs for everyone. There are other measures that should be considered as well. I raised the idea of banning television advertising of prescription drugs in an earlier post - http://davideisenthal.typepad.com/the_eisenthal_report/2005/04/considering_hea.html. This may not be practicable, but ideas like this need to be considered. I don't have all - or even many - of the answers on these issues, but I do think that it is important to consider a wide spectrum of ideas.

"My main point in this post and others is that accelerating health cost increases are unsustainable."

A-freakin'-MEN!

"I raised the idea of banning television advertising of prescription drugs in an earlier post"

Yeah, that's another one that gets me...reimposing that ban would have to be on a national level to really have an impact, but from what I understand, bigpharma now spends more money advertising than it does on R&D (and it still complains "but drugs HAVE to be that expensive! R&D costs a lot!"). It also has a detrimental impact on health care. In this day and age, when insurance companies are hustling people in and out quick-quick in the Dr's office, you'd think having people more knowledgeable about drugs would be a positive impact...but dr's complain that patients insist on a drug they've heard of whether or not there's another solution, or even another drug, because they heard about it on TV. I don't have numbers (sorry, I'm in the middle of a City Council post, no time to look it up) but from what I remember reading, a lot of unnecessary prescriptions are being passed out by harried dr's who have no time to sit down and really discuss these things with patients.

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